Basic Information
| Provider Information | |||||||||
| NPI: | 1740411792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANDERS DENTAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 761 W TUNNEL BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703605545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858765430 | ||||||||
| FaxNumber: | 9858760455 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 W TUNNEL BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703605545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858765430 | ||||||||
| FaxNumber: | 9858760455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2009 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | HART | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9858765430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 4648 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1846481 | 05 | LA | MEDICAID |